Healthcare Provider Details

I. General information

NPI: 1063913788
Provider Name (Legal Business Name): MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 US HIGHWAY 25 E
MIDDLESBORO KY
40965-1861
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858-0040
US

V. Phone/Fax

Practice location:
  • Phone: 606-654-9450
  • Fax: 606-302-4240
Mailing address:
  • Phone: 606-633-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number700017
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DELENA P MILLER
Title or Position: CREDENTIALING
Credential:
Phone: 606-633-4823